Vital Signs - Unit 1 (Basics & TEMP) Flashcards

1
Q

What are the 5 vital signs?

A

Body Temp, Pulse, Blood Pressure, Respirations and Pain

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2
Q

Why do we take vital signs?

A

To get an idea of what’s going on.

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3
Q

When to take vital signs?

A

per agency policy, doctor’s order’s, on admission (baseline), prior to discharge, when a client has a change in health status, before or after surgery or procedure, before and/or after giving certain medication, before/after nursing interventions, nursing judgment/PRN.

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4
Q

Body Temp = balance between heat ___ and heat ___ by the body.

A

Produced/lost.

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5
Q

What are the two types of body temps? Give examples!

A

Core (abdominal cavity, cranial, etc.) and Surface (temp of skin, mucous layer, etc.)

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6
Q

What is considered a normal temp?

A

98-98.6 F (but 97-100 can be normal, too.)

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7
Q

What are some factors that effect body heat production?

A

BMR (cost of energy of things such as breathing, eating, etc.), thyroxin output (produced by the thyroid), fever, Epi, etc.

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8
Q

What are the five most common sites for measuring temperature?

A

Oral, rectal, axillary, and tympanic and temporal!

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9
Q

Oral and Temporal Temps are most accurate. T/F?

A

True!

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10
Q

If a person has eaten or drank something hot or cold within 30 minutes of getting the temp, it’s fine. T/F?

A

False - you have to wait 30 minutes!

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11
Q

Oral Temp - least accessible and convenient. T/F?

A

False - it is the most accessible and convenient!

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12
Q

Rectal Temp - possible perforation of the ___. It is also ____.

A

Bowel/embarrassment.

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13
Q

With a rectal temp, we can walk away while it’s being done. T/F?

A

False - we have to stay there!

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14
Q

Axillary Temp - least safe and very invasive. T/F?

A

False - it is very safe and very non-invasive!

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15
Q

Tympanic Membrane Temp - it is __ accessible, reflects the __ temp, and is very fast.

A

readily/core.

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16
Q

Bladder and esophageal temps - most or least reliable?

A

Most!

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17
Q

Which temp is best for older people?

A

Axillary!

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18
Q

What are the 5 types of thermometers?

A

Electronic, Tympanic Membrane, Chemical Disposable, Temperature Sensitive Tape, and Mercury

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19
Q

What regulates the body temp? Think anatomy….

A

Shell and Core, Hypothalamus, Sensory Receptors.

20
Q

Temp Set Point - it is the …

A

control center of body temp level at which the hypothalamus maintains temp.

21
Q

If we get too cold, __ is released.

A

Epi (vasoconstriction.)

22
Q

If we get too warm, we ___.

A

Sweat (vasodilation.)

23
Q

What are some factors affecting body temp?

A

Age, diurnal variation (circadian rhythms), exercise, hormones, stress, environment, etc.

24
Q

Around what time of day are our temps the highest and lowest?

A

4p-8p = highest.

2-6 AM = lowest.

25
Q

What are the four common types of Temps?

A

Intermittent, Remittent, Relapsing, Constant.

26
Q

Intermittent Fever - def

A

Body temp fluctuates between periods of fever and no fever.

27
Q

Remittent Fever - def

A

body temp fluctuates more than 3.6 degrees above normal and does not go back to normal between fluctuations. It is above 102.2 and doesn’t go below that.

28
Q

Relapsing Fever - Def

A

body temp returns to normal for at least a day, then comes back.

29
Q

Constant fever -def

A

body temps remains constantly elevated, but always less than 3.6 degrees (doesn’t go above 102.2)

30
Q

What are some symptoms of a fever?

A

Increased HR, hot/dry skin, thirst, flushed face, etc.

31
Q

Infant fever - above ___ is considered signifiant.

A

100.4

32
Q

Infants and children are at a greater risk for febrile convulsions as the fever is elevating. T/F?

A

True!

33
Q

Adult __ - ___ = low grade favor.

A

98.8-100.4

34
Q

Above __ = significant fever.

A

100.4

35
Q

Above ___ = Hyperpyrexia.

A

105.8

36
Q

Nursing Interventions for Clients with fever - what are some?

A

Monitor vital signs frequently, provide adequate nutrition and fluids, measure input and output, remove excess blankets unless chilled or shivering.

37
Q

Hyperthermia = non-regulated elevation in body temp with an imbalance between heat gain and heat loss. T/F?

A

True!

38
Q

Hyperthermia - set point is/is not elevated?

A

Is not!

39
Q

Neurogenic Fever - fever that is not elevating the set point. T/F?

A

True!

40
Q

What are some heat exhaustion symptoms?

A

S&S weakness, fatigue, headache, giddiness, anorexia, nausea, etc.

41
Q

Heat stroke - symptoms?

A

Hot, dry skin, absence of sweating, neurological symptoms - confusion, coma, seizures, acute renal failure, etc.

42
Q

Malignant Fever - def

A

autosomal dominant genetic disorder that affects calcium levels within the skeletal muscle - occurs with administration of anesthesia. Dantrolene is given.

43
Q

How do we treat hypothermia?

A

Prevent is, warm air spray, cooling blanket, etc.

44
Q

Hypothermia - decrease what?

A

Body temp, pulse, and respirations.

45
Q

Hypothermia - what else is a part of this?

A

Severe shivering (initially), feelings of cold and chills, hypotension, disorientation, etc.

46
Q

How do we treat a patient with hypothermia?

A

Provide a warm environment, provide dry clothing, apply warm blankets, cover the scalp with a cap or turban, etc.